Senior Manager - Prior Authorization

The Prior Authorization Senior Manager is responsible for overseeing the daily operations of the prior authorization department. This role involves leading a team to ensure all required prior authorizations are obtained accurately and in a timely manner for patient services, medications, and procedures. The manager will develop and implement efficient workflows, monitor key performance indicators, ensure compliance with all payer and regulatory requirements, and serve as a key resource for staff and clinical teams. The ultimate goal is to minimize claim denials, reduce delays in patient care, and optimize the revenue cycle.

Key Responsibilities:

Leadership and Team Management:

• Lead, train, and mentor a team of prior authorization specialists.
• Manage daily workflow, delegate tasks, and ensure productivity goals are met.
• Conduct performance reviews, provide constructive feedback, and identify opportunities for professional development.

Operational Oversight:

• Oversee the end-to-end prior authorization process for all requested services.
• Develop and implement standard operating procedures (SOPs) to streamline workflows and improve efficiency.
• Monitor and analyze key performance indicators (KPIs) such as approval rates, turnaround times, and denial trends.

Compliance and Quality Assurance:

• Ensure all prior authorization activities adhere to federal, state, and payer-specific regulations.
• Conduct regular audits of submitted authorizations to maintain a high level of accuracy and quality.
• Stay current with changes in payer policies, medical necessity criteria, and coding guidelines.

Communication and Collaboration:

• Serve as the primary point of contact for clinical staff and providers regarding prior authorization requirements.
• Collaborate with the billing, coding, and patient financial services departments to resolve complex issues and prevent future denials.
• Communicate with insurance companies and third-party payers to appeal denied authorizations.

Desired Candidate:

• Over 15 years of experience in prior authorization, medical billing, and revenue cycle management, with 23 years in a leadership role.
• Expert in prior authorization processes across specialties, insurance policies, EHR systems, and healthcare compliance (HIPAA).
• Strong leadership, analytical, and problem-solving skills with proven ability to manage priorities and drive operational excellence.

Kmohan3@primehealthcare.com / Saddla@primehealthcare.com